Scand J Med Sci Sports 2014: 24: 439446

doi: 10.1111/j.1600-0838.2012.01505.x

2012 John Wiley & Sons A/S.

Published by John Wiley & Sons Ltd

Adolescent elite athletes cigarette smoking, use of snus,

and alcohol
M. Martinsen1, J. Sundgot-Borgen2
Oslo Sport Trauma Research Center, The Norwegian School of Sport Sciences, Oslo, Norway, 2Department of Sports Medicine, The
Norwegian School of Sport Sciences, Oslo, Norway
Corresponding author: Marianne Martinsen, Oslo Sport Trauma Research Center, The Norwegian School of Sport Sciences, Oslo
0806, Norway. Tel: +47 23 26 22 64, Fax: +47 22 23 42 20, E-mail: marianne.martinsen@nih.no

Accepted for publication 12 June 2012

The purpose was to examine cigarette smoking, use of

snus, alcohol, and performance-enhancing illicit drugs
among adolescent elite athletes and controls, and possible
gender and sport group differences. First-year students at
16 Norwegian Elite Sport High Schools (n = 677) and two
randomly selected high schools (controls, n = 421) were
invited to participate. Totally, 602 athletes (89%) and 354
(84%) controls completed the questionnaire. More controls than athletes were smoking, using snus, and drinking alcohol. Competing in team sports was associated
with use of snus [odds ratio = 2.8, 95% confidence interval (CI) 1.6 to 4.7] and a similar percentage of male and

female handball (22.2% vs 18.8%) and soccer players

(15.7% vs 15.0%) reported using snus. For controls, not
participating in organized sport was a predictor for
smoking (odds ratio = 4.9, 95% CI 2.2 to 10.9). Female
athletes were more prone to drink alcohol than males
(46.3% vs 31.0%, P < 0.001). Only, 1.2% athletes and
2.8% controls reported use of performance-enhancing
illicit drugs. In conclusion, use of legal drugs is less
common among athletes, but this relationship depends on
type of sport and competition level. The association
between team sports and use of snus suggests that sport
subcultures play a role.

The use of snus is on the rise in Norway (Lund &

Lindbak, 2007), Sweden (Lundqvist et al., 2009),
Finland (Huhtala et al., 2006), and the US (Alpert et al.,
2008). During the last few years, the largest increase has
been among young people (Lund & Lindbak, 2007).
Furthermore, it has been shown that young people who
initiate tobacco use through using snus have many of the
same predisposing factors as young smokers (Hagquist,
2007), which may indicate that the products recruit users
from the same segment of the population (Lund et al.,
2011). Finally, a recent Norwegian study found that adolescents socioeducational status was associated with
smoking for boys and girls, while there was no similar
association with snus use (Overland et al., 2010).
Traditionally, it is believed that participation in sports
lead to a healthier lifestyle and less use of recreational
drugs (Pate et al., 1996; Baumert et al., 1998) and it has
been reported that participation in sport may act as a
protective factor against risky behavioral habits, such as
alcohol, tobacco, or illicit drug use among adolescent
athletes (McArdle et al., 2000; Pate et al., 2000; Bu
et al., 2002). On the other hand, studies that have
included older athletes suggest that sport participation
may be associated with greater behavioral risk (Gay
et al., 1990; Hildebrand et al., 2001), and that young
athletes are more likely to use smokeless tobacco, have

an increased risk of alcohol use, and binge drink more

than non-athletes (Rainey et al., 1996; Melnick et al.,
2001). In addition, some studies have reported a higher
prevalence of snus use among high school athletes compared with non-athletes (Hu et al., 1996; Melnick et al.,
2001), while other studies have reported no difference
(Buckhalt et al., 1992; Rainey et al., 1996; Baumert
et al., 1998). The association between sports participation and the risk behaviors of drug use among
adolescent athletes seems to depend on the kind of drug
(Wechsler et al., 1997), type of sport (Challier et al.,
2000) as well as gender (Kokotailo et al., 1996; Pate
et al., 1996). Studies including adolescent elite athletes
representing many different sports are deficient.
Because use of snus, smoking, and drinking is associated with health risks, and alcohol and smoking might
have negative effects on performance, it was important
to examine the prevalence of athletes using these drugs.
Furthermore, the recent years increase in use of snus has
been largest among young people (Lund & Lindbak,
2007; Lund et al., 2011), and practical experience and
some studies indicate that use of especially snus also is
common among young athletes (Melnick et al., 2001;
Haukkala et al., 2006). Thus, there is a need for a
study which includes a representative population of adolescent elite athletes representing a wide range of sports

439

Martinsen & Sundgot-Borgen

Table 1. Classification of the 50 different sports into individual/team sports

Individual sports
(n = 242)
Dancing
High jump
Middle- and long distance running
Karate
Tae kwon do
Fencing
Hammer
Hurdle
Javelin
Ski jump
Swimming

Team sports
(n = 360)
Hepathlon
Decathlon
Long jump
Triple jump
Judo
Golf
Shooting
Gymnastics
Tennis
Sailing

Snowboard
Chess
Table tennis
Freestyle
Motocross
Snow cross
Surfing
Dog racing
Paddling
Rowing/sculling
Alpine skiing

and in which athletes and controls fill out the same

questionnaires.
Therefore, the purpose of this study was to examine
the prevalence of cigarette smoking, alcohol use, snus
use (low-nitrosamine smokeless tobacco, Swedish type),
and use of performance-enhancing illicit drug among
elite adolescent athletes representing 50 different sports
and age-matched controls. Our research questions were
as follows:
1. To what extent do adolescent elite athletes smoke,
use snus, drink alcohol, and/or use performanceenhancing illicit drugs?
2. Is sport type and gender associated with the use of
snus, alcohol, cigarettes, and performance-enhancing
illicit drugs?
We hypothesized that cigarette smoking, use of snus,
alcohol, and performance-enhancing illicit drugs were
less common among both male and female athletes
compared with controls. Furthermore, we hypothesized
that cigarette smoking, use of snus, alcohol, and
performance-enhancing illicit drugs were associated
with type of sport and gender.
Materials and methods
Study design and participants
The participants in this study consisted of the total population of
adolescent elite athletes (677 athletes) attending the Elite Sport
High Schools in Norway (n = 16) and age-matched controls in two
regular high schools (n = 421). An inclusion criterion was enrollment as a first-year student at one of the Norwegian Elite Sport
High Schools (athletes) or at one of the two randomly selected
high schools in Buskerud County in Norway (controls) and a birth
date in 1992. Norwegian Elite Sport High Schools are selective,
private and public high schools designed for highly talented athletes. The schools provide the best conditions possible, combining
education and sports, and give athletes the opportunities to
compete on a national or an international level and at the same
time acquire high school graduation. Following initial screening,
711 athletes and 500 controls during the autumn of 2008 were
invited to participate. A total of 29 athletes and 77 controls were
excluded from the study (exclusion due to age: n = 29 athletes and

440

Nordic combined
Cross country skiing
Cycling
BMX-cycling
Mountain-biking
Biathlon
Orienteering
Sprint
Discus
Horse riding

Basketball
Soccer
Handball
Floorball
Ice hockey
Volleyball
Beach volleyball

60 controls, no informed consent: n = 5 athletes and 19 controls).

Of the 677 athletes and 421 controls eligible for the study, 66
athletes and 66 controls did not participate, and 14 athletes and
two controls did not complete the questionnaire satisfactorily. A
total of 602 athletes and 354 controls completed the study, giving
a response rate of 89% for the athletes and 84% for the controls.
The athletes represented 50 different sports. For part of the analysis, the sports were classified into individual sports and team sports
as seen in Table 1. The study was approved by the Regional Committee for Medical and Health Science Research Ethics in Southern Norway and by the Norwegian Social Science Data Services.
The respondents gave written consent to participate. Permission
from parents to participate was required, and consent to collect
data was obtained from the head of each school.

Data collection
Questionnaire
A questionnaire including questions regarding health, use of
tobacco, alcohol, and performance-enhancing illicit drugs, training and physical activity history, and eating behavior was administered to the respondents. Smoking and use of snus were
measured by questions that separated never, occasional, and daily
users. The questions were: Are you smoking cigarettes now? and
Are you using snus now? With the categories: (1) yes, every day;
(2) yes, occasionally; and (3) no. To measure the use of alcohol,
the question was: Do you drink alcohol? with the following
categories: (1) yes and (2) no. If the respondents answered yes,
they were asked how often they used to drink/were drinking
alcohol with the following categories: (1) less than once a month;
(2) one to three times a month; (3) once a week; and (4) several
times a week. Performance-enhancing illicit drug use was measured by the question: Do you use or have you ever used any
performance enhancing illicit drugs? with the categories: yes and
no. The athletes and the controls completed the questionnaire at
school during school hour in the presence of one of the research
group members. The participants were informed that an ID
number was written on the questionnaire to make sure the analysis
of the data was an anonymous process.

Statistical analysis
The statistical analyses were carried out using PASW Statistics 18
for Windows (IBM Corporation, Route, Somers, NY, USA).
Results are expressed as mean values standard deviation for
continuous data and absolute numbers (n) and percentages (%) for

Tobacco and alcohol use among elite athletes

Table 2. Prevalence of tobacco use among athletes and controls

Occasional snus (%)

Females
Males
Total

Daily snus (%)

Athletes

Controls

Athletes

Controls

Athletes

Controls

20 (9.2)
45 (11.7)
65 (10.8)

24 (15.4)
30 (15.2)
54 (15.3)

0.066
0.242
0.044

6 (2.8)
29 (7.6)a
35 (5.8)

14 (9.0)
42 (21.2)b
56 (15.8)

0.008
<0.001
<0.001

26 (11.9)
74 (19.3)c
100 (16.6)

38 (24.4)
72 (36.4)d
110 (31.1)

0.002
<0.001
<0.001

Occasional smoke (%)

Females
Males
Total

Snus, total (%)

Daily smoke (%)

Smoke, total (%)

Athletes

Controls

Athletes

Controls

Athletes

Controls

3 (1.4)
2 (0.5)
5 (0.8)

18 (11.5)
25 (12.6)
43 (12.1)

<0.001
<0.001
<0.001

7 (4.5)
11(5.6)
18 (5.1)

*
*
<0.001

3 (1.4)
2 (0.5)
5 (0.8)

25 (16.0)
36 (18.2)
61 (17.2)

<0.001
<0.001
<0.001

Values are given in numbers and (percentage).

*Because of small numbers, no statistical analysis was performed.
a
P = 0.016 compared with female athletes;
b
P = 0.002 compare d with female controls;
c
P = 0.020 compared with female athletes;
d
P = 0.015 compared with female controls.

categorical data. The independent sample t-test was used to evaluate mean differences, and chi-square tests examined categorical
frequencies. For chi-square tests in which one of the variables had
more than two categories, linear-by-linear associations were used.
For the athletes, two different binary logistic regression analyses
were carried out for predicting the likelihood between use of snus
and alcohol as the dependent variable and gender, sports group
(team/individual), and smoking, snus/alcohol as fixed factors.
Only 0.8% of the athletes reported smoking, and thus, a third
binary logistic regression analysis with smoking as the dependent
variable was only carried out for the controls. For controls, instead
of sports group, they were asked whether they were involved with
organized sports (yes/no). Because only 1.2% and 2.8% for athletes and controls reported use of performance-enhancing illicit
drugs; no statistical analyses including this variable were performed. Odds ratios (ORs) are given with 95% confidence intervals (CIs). The significance level was set to 0.05.

Results
Participant characteristics
All participants were born in 1992, but the athletes
were slightly younger than the controls at the data
collection time (16.5 0.3 vs 16.9 0.3, P < 0.001).
Among the controls, 54% met the Norwegian health
recommendation for physical activity (1 h per day of
moderate activity) (Sosial- og helsedirektoratet, 2000).
Athletes reported training14.2 4.5 h/week. A total of
22.3% of the athletes had competed at the international
level.

organized sport compared with those participating in

organized sports reported smoking (23.7% vs 7.1%,
P < 0.001). Furthermore, not participating in organized
sport (OR = 4.9, 95% CI 2.2 to 10.9, P < 0.001), use of
snus (OR = 6.3, 95% CI 3.2 to 12.6, P < 0.001) and
alcohol (OR = 13.5, 95% CI 3.1 to 58.6, P = 0.001)
proved to be significant predictors for smoking among
controls.
In addition, a higher percentage of controls compared
with athletes reported use of snus (31.1% vs 16.6%,
P < 0.001), as well as a higher percentage of male athletes than female athletes (19.3% vs 11.9%, P = 0.020)
and control males than control females (36.4% vs
24.4%, P = 0.015) (Table 2). Forty-one percent of the
controls reporting use of snus were occasional or daily
smokers. In addition, five athletes reported smoking and
four of these also reported using snus.

Use of alcohol
A higher percentage of controls compared with athletes
(63.0% vs 36.5%, P < 0.001) and female compared with
male athletes (46.3% vs 31.0%, P < 0.001) reported
drinking alcohol. Furthermore, a higher percentage of
the controls who reported drinking alcohol reported
drinking one to three times a month compared with athletes (Table 3). Only males (athlete and control) reported
drinking several times a week.

Smoking and use of snus

Table 2 shows that cigarette smoking (daily or occasional) was less common among athletes than controls
(0.8% vs 17.2%, P < 0.001). There was no difference in
prevalence of smoking between males and females.
However, a higher percentage of controls not involved in

Use of performance-enhancing illicit drugs

A total of seven athletes, 1.2% (one female and six
males), and 10 controls, 2.8% (three females and seven
males), reported use of performance-enhancing illicit

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Martinsen & Sundgot-Borgen

Table 3. Athletes and controls who reported use of alcohol

Variable

Females

Less than once a month

13 times a month
Once a week
Several times a week

Males

Athletes

Controls

n = 94

n = 103

67 (71.3)
24 (25.5)
3 (3.2)

33 (32.0)
65 (63.1)
5 (4.9)

<0.001
<0.001
*
*

Athletes

Controls

n = 117

n = 120

79 (67.5)
35 (29.9)
2 (1.7)
1 (0.9)

26 (21.7)
76 (63.3)
15 (12.5)
3 (2.5)

<0.001
<0.001
*
*

Values are given in numbers and (percentage).

Data regarding frequency was not available for nine athletes.
*Because of small numbers, no statistical analysis was performed.

Table 4. Prevalence of alcohol and snus use among athletes competing in individual and team sports

Variable

Current snus use

Daily/occasional
Use of alcohol
Yes

Females

Males

Individual

Team

n = 104

n = 114

Total

Individual

Team

n = 137

n = 247

Individual

Team

n = 241

n = 361

7 (6.7)

19 (16.7)

0.024

16 (11.7)

58 (23.5)

0.005

23 (9.5)

77 (21.3)

<0.001

47 (45.2)a

54 (47.4)b

0.75

41 (30.0)

78 (31.6)

0.74

88 (36.5)

132 (36.6)

0.99

Values are given in numbers (percentage).

a
P = 0.015 compared with male athletes competing in individual sports;
b
P = 0.004 compared with male athletes competing in team sports.

Table 5. Logistic regression analysis with use of snus and use of alcohol as the dependent variables in athletes and controls

Use of snus
B
Athletes
Gender
Team sport
Use of alcohol/snus
Smoking
Controls
Gender
Not organized sport
Use of alcohol/snus
Smoking

Use of alcohol
Odds ratio (95% CI)

Odds ratio (95% CI)

0.865
1.016
1.643
3.101

2.4 (1.4 to 4.0)

2.8 (1.6 to 4.7)
5.2 (3.2 to 8.4)
22.2 (2.3 to 211)

0.001
<0.001
<0.001
0.007

-0.825
-0.105
1.633
0.836

0.44 (0.3 to 0.6)

0.90 (0.6 to 1.3)
5.1 (3.2 to 8.3)
2.3 (0.2 to 22.6)

<0.001
0.57
<0.001
0.47

0.771
0.035
1.714
1.838

2.2 (1.2 to 3.7)

0.97 (0.6 to 1.7)
5.5 (2.8 to 11.0)
6.3 (3.1 to 12.5)

0.006
0.90
<0.001
<0.001

-0.498
-0.163
1.703
2.551

0.61 (0.4 to 1.0)

0.85 (0.5 to 1.4)
5.5 (2.8 to 10.9)
12.8 (3.0 to 55.5)

0.048
0.52
<0.001
0.001

CI, confidence interval.

drugs. None of the athletes reported which performanceenhancing illicit drugs they used.
Snus and alcohol use among athletes in different
sport groups
Use of snus was more common among athletes competing in team sports than in individual sports (21.3% vs
9.5%, P < 0.001) (Table 4). There was no difference
between the sport groups and use of alcohol (team 36.6%

442

vs 36.5%, P = 0.99), but a higher prevalence of female

athletes in both individual and team sports vs male athletes in the same sport groups reported use of alcohol
(Table 4).With logistic regression analysis, team sports
proved to be a significant predictor for use of snus and
gender for drinking alcohol among athletes (Table 5).
Also, smoking was strongly associated with snus, but
due to few smokers among the athletes, the CI was very
high. Still, use of snus was at least 2.3 times as high
among smokers as non-smokers. In addition, use of snus

Tobacco and alcohol use among elite athletes

Table 6. Prevalence of snus use among the different team sports

Daily

Ice hockey, n = 47
Floorball, n = 12
Handball, n = 100
Soccer, n = 180
Basketball, n = 16

Occasional

Total (daily or occasional)

Females

Males

Total

Females

Males

Total

Females

Males

Total

2 (3.1)
4 (10.0)

8 (17.0)

3 (8.3)
10 (7.1)
3 (21.4)

8 (17.0)

6 (5.0)
14 (7.8)
3 (18.8)

12 (25.5)
5 (50.0)
5 (13.9)
12 (8.6)

12 (25.5)
6 (50.0)
15 (15.0)
14 (7.8)

20 (42.6)a
5 (50.0)
8 (22.2)
22 (15.7)
3 (21.4)

20 (42.6)a, b
6 (50.0)*
20 (20.0)
28 (15.6)
3 (18.8)*

1 (50.0)
10 (15.6)
2 (5.0)

1 (50.0)
12 (18.8)
6 (15.0)

Values are given in numbers and (percentage).

*Because of small numbers, no analyses were performed.
a
P < 0.001 compared with soccer;
b
P < 0.01 compared with handball.

was a strong predictor for alcohol use, and athletes who

reported using snus were over five times more likely to
report drinking alcohol than athletes not reporting using
snus (Table 5).
Most of the athletes competing in team sports were
involved in handball, soccer, or ice hockey (Table 6).
Volleyball players were also included in this study, but
none of the volleyball or beach volleyball players
reported use of snus.
Snus and alcohol use among controls in
organized sports
Among controls, we found no difference in snus use and
alcohol drinking between those involved in organized
sports compared with those not involved in such activities (snus: 28.1% vs 33.0%, P = 0.324; alcohol: 60.4%
vs 64.7%, P = 0.422). However, gender proved to be a
significant predictor of snus and alcohol use, where male
controls were more likely to use snus and female controls more likely to use alcohol compared with each
other (Table 5). In contrast to the athletes, smoking was
a strong predictor for both snus and alcohol use among
the controls.
Discussion
The main finding in this study was the higher prevalence
of smoking, snus, and alcohol use among the controls
compared with the elite adolescent athletes, and that
female athletes were more prone to drink alcohol than
male athletes. Furthermore, a higher frequency of athletes competing in team sports vs individual sports
reported use of snus, and a similar percentage of male
and female athletes in handball (22.2% vs 18.8%) and
soccer (15.7% vs 15.0%) reported use of snus. Finally,
for both athletes and controls, snus use proved to be a
strong predictor for alcohol drinking.
In contrast to some studies (Hu et al., 1996; Davis
et al., 1997; Tomar & Giovino, 1998; Melnick et al.,
2001), snus use was less common among athletes than

controls (16.6% vs 31.1%, P < 0.001) in our study. The

discrepancy from the results in the other studies might be
explained by the fact that all the athletes included in this
study are elite upcoming athletes attending Elite Sport
High Schools in which snus use is forbidden or not
accepted. Another explanation might be the possibility
that some of the athletes are conscious about the health
risks and the negative performance effects snus might
have (Strmme, 1989). In accordance with other studies
on adolescent athletes (Huhtala et al., 2006; Grotvedt
et al., 2007), we found a higher prevalence of snus use
among male athletes than female athletes and a wide
variation in the patterns of snus use in different sports
(Walsh et al., 1994; Green et al., 2001; Alaranta et al.,
2006). Our finding that snus use was more common
among team sport athletes than athletes in individual
sports is in accordance with the results from Alaranta
et al. (2006). They reported snus use to be more common
in team sports compared with other sports and controls.
In our study, the prevalence of snus use was almost three
times higher for athletes competing in team sports than
individual sports (OR = 2.8, 95% CI 1.6 to 4.7). Furthermore, and as expected, snus use was more common in
ice hockey as compared with soccer and handball. We
were surprised to find that 20.0% of all male and female
handball players used snus and that the prevalence in
handball was as high as in soccer (15.6%, P = 0.344). In
Sweden, snus use is more common among adolescent ice
hockey players than the general male population, and
snus use is more common than smoking among male ice
hockey players, and the use of snus is higher among ice
hockey players than in any other sports (Rolandsson &
Hugoson, 2000, 2001, 2003; Galanti et al., 2001). These
findings suggest that the subculture of a particular sport
might socialize athletes into use of drugs such as snus. It
has also been reported that the ice hockey environment is
more linked to snus use as compared with other sports
(Rolandsson et al., 2006). Athletes in the Rolandsson
et al. study (2006) also reported that athletes experienced
snus use among older players and coaches at an early
age. Due to the feeling of a consenting attitude from the

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Martinsen & Sundgot-Borgen

coaches regarding snus use compared with smoking, athletes thought that their coaches believed smoking would
affect the physical condition more than using snus.
Therefore, athletes think that coaches imply a consenting
attitude to ward snus use (Rolandsson et al., 2006). From
our questionnaire, we are not able to conclude that this
also is the case in our study, but the fact that team sports
was a significant predictor for snus use and not for
alcohol use, the higher prevalence in sports such as ice
hockey and soccer might indicate that collective thinking, peer pressure, and the environment in which the
athletes practice their sport also have a significant impact
on these young athletes.
In Norway, the minimum legal age for buying
tobacco and alcohol is 18, and since 2004, it has been
illegal to smoke in restaurants and bars. For the general
population, this ban may have effected changes in the
preference of tobacco type being preferred among
tobacco users. Although the sale of tobacco for smoking
has decreased and the sale of snus has increased, still
more people are smoking than using snus in Norway
(Lund & Lindbak, 2007). In contrast to the situation in
Norway, the sale of snus is illegal in all European countries included in the European Union except for Sweden
where snus use is believed to reduce the prevalence of
smoking (Fagerstrom & Schildt, 2003; Rodu & Cole,
2004; Ramstrom & Foulds, 2006). Recent Norwegian
data have also shown an association between use of
snus and quit rates for smoking, and thus support the
hypothesis that the availability to snus increases the
quit-smoking ratio (Lund et al., 2011). However, in contrast to Sweden, almost half of Norwegian snus users
use snus only occasionally (Lund & Lindbak, 2007),
and in this group, the quit ratio for smoking is low
(Lund et al., 2011). Furthermore, surveys including
young snus users (1620 years) indicate that almost half
of them are primary users, and thus, the quit ratio for
smoking may be very low in this age group (Lund et al.,
2011). In our study, we had very few athletes that are
combination users (smokers and snus users) and only
five athletes reported smoking. Thus, most of the athletes who reported using tobacco were primary snus
users. In contrast, one in five of the controls reported
smoking daily or occasionally, and smoking proved to
be a strong predictor for snus use. The finding that
controls involved in organized sport were less likely
to smoke compared with those not involved with
organized sport is in accordance with previous studies
reporting that fewer physically active adolescents are
smoking compared with less physically active peers
(Thorlindsson et al., 1990; Pate et al., 1996; Melnick
et al., 2001). Thus, participating in sports seems to be
associated with no smoking. It is well known that use of
cigarettes at a regular basis reduces physical ability and
it has been suggested that the low number of smoking
athletes is due to the awareness of the detrimental effect
on health and performance (Pederson et al., 1992;

444

Wechsler et al., 1997; Melnick et al., 2001). This might

explain why only five athletes in our study reported
smoking (occasionally). Similar to snus use, smoking
by adult role models constitutes a powerful influence on
the smoking behavior of adolescents (Melnick et al.,
2001). Because coaches, athletic trainers, and older athletes are less likely to smoke, it has been speculated that
athletes have more positive role models than nonathletes which may lower their risk of becoming
smokers (Melnick et al., 2001).
An interesting finding was that gender proved to be a
significant predictor for alcohol use among the athletes
in this study. More females than males reported drinking
alcohol (46% vs 31%, P < 0.001). Research comparing
the prevalence of alcohol use among athletes and nonathletes has shown conflicting results. Martens and colleagues (2006) systematic review of college athletes
drinking behavior revealed inconsistent findings, some
studies indicated that athletes consumed more alcohol
than non-athletes and other indicated no differences or
less consumption of alcohol. A recent review by (Lisha
& Sussman, 2010) found that 22 of the 29 studies that
examined the relationship between participation in
sports and alcohol consumption reported a positive association. Our findings of lower prevalence of alcohol use
among the athletes compared with the controls concur
with a study by Peretti-Watel et al. (2003). But, it should
be mentioned that in their study, data representing separate databases and a different age range were included
and therefore, a comparison is not necessarily appropriate. Among our athletes, we found no differences in
drinking frequency, and only one male athlete reported
drinking several times a week. Unfortunately, our study
was not designed to test the hypothesis that athletes have
different drinking habits depending on being in or off
season and the assumption that athletes binge drink
more than non-athletes. The study by Green et al. (2001)
investigating substance abuse habits in college student
athletes indicated that there were higher rates of alcohol
use and more binge drinking among college athletes than
non-athletes.
We found no difference in the prevalence of
performance-enhancing illicit drug use between athletes
(1.2%) and controls (2.8%). Additionally, the low
number of both athletes and controls reporting such use
made further analysis between gender and different sport
groups impossible. Our results might indicate that there
is no culture for Norwegian adolescent elite athletes to
use performance-enhancing illicit drugs. On the other
hand, the athletes in our study might have underreported
the use in fear of being detected and eventual consequences because many of the Elite Sport High Schools
have strict rules on drug use. However, this is in agreement with the findings reported in Lisha & Sussman
(2010). Nine of the 15 studies found a relationship
between sport participation and low use of illicit drugs
(using a broad definition). A positive relationship was

Tobacco and alcohol use among elite athletes

found in two studies (Green et al., 2001; Rockafellow &
Saules, 2006), and three studies indicated that the relationship depended on gender and type of sport (Ewing,
1998; Peretti-Watel et al., 2002; Ford, 2007). Due to the
conflicting results regarding the use of illicit drugs
among athletes and the lack of studies including adolescent elite athletes, we suggest that the relationship
between participation in competitive sport and use of
illicit drugs should be further examined. More studies
should include adolescent elite athletes and specific type
of drug (both performance-enhancing and recreational)
to determine the directionality of the possible relationships, and thus, better inform future drug prevention
efforts in this domain.
This study was limited by the same conceptual and
methodological concerns that apply to all cross-sectional
studies; it is impossible to determine whether a causeand-effect relationship exists. Furthermore, most of the
Norwegian Elite Sport High Schools have regulations on
use of drugs. This might have affected the results. Athletes may have underreported their use of drugs due to
their fear of being discovered. Another limitation is that
we did not ask the athletes if their use of drugs changed
during the season. This may have affected the results. On
the other hand, our inclusion of a large number of sports
may have eliminated this limitation because both in and
out of season athletes were included in this study.
Perspectives
Competing in sport at a high level during adolescence
seems to be associated with less smoking, drinking, and

snus use as compared with adolescent not participating

in competitive sports. On the other hand, taken into consideration the fact that the athletes included in this study
are upcoming elite athletes, the percentage of the athletes reporting drinking alcohol and snus use is worth
noticing. Also, the finding that representing a team sport
was a predictor for snus use indicates that young elite
athletes competing in team sports such as handball, football, and ice hockey might be at increased risk of using
snus. Due to the high response rate and large number of
sports included, we believe that results from this study
are generalizable to other elite adolescent athletes
representing team and individual sports. Therefore, it is
essential to continue and further develop sport-specific
prevention programs against the use of recreational
drugs and especially snus among both male and female
athletes and non-athletes.
Key words: recreational drugs, drinking, performance,
smokeless tobacco, non-athletes.

Acknowledgements
We acknowledge the comments of Professor Glyn Roberts in the
preparation of this manuscript. We also thank all the subjects and
their coaches for cooperation and support during this study. The
Oslo Sport Trauma Research Center has been established at the
Norwegian School of Sport Sciences through generous grants
from the Royal Norwegian Ministry of Culture, the South-Eastern
Norway Regional Health Authority, the International Olympic
Committee, the Norwegian Olympic Committee & Confederation
of Sport, and Norsk Tipping AS. This project has been established
through a grant from Olympiatoppen.

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